Audrey L. Jones

Perceived Discrimination in Health Care and Mental Health/Substance Abuse Treatment Among Blacks, Latinos, and Whites.

Background: Experiences of discrimination in health care settings may contribute to disparities in mental health outcomes for blacks and Latinos. We investigate whether perceived discrimination in mental health/substance abuse visits contributes to participants’ ratings of treatment helpfulness and stopped treatment. Research Methods: We used data from 3 waves of the California Quality of Life Survey, a statewide population-based telephone survey assessing mental health/substance disorders and their treatment. In a sample of 1099 adults (age 18–72) who indicated prior year mental health/substance abuse visits, we examined: experiences of discrimination that occurred during health care and mental health/substance abuse visits, ratings of treatment helpfulness, and reports of stopping treatment early. Results: Fifteen percent of California adults reported discrimination during a health care visit and 4% specifically during mental health/substance abuse visits. Latinos, the uninsured, and those with past year mental disorders were twice as likely as others to report health care discrimination [adjusted odds ratio (AORs)=2.08, 2.77, and 2.51]. Uninsured patients were 7 times more likely to report discrimination in mental health/substance abuse visits (AOR=7.27, P<0.01). The most commonly reported reasons for health care discrimination were race/ethnicity for blacks (52%) and Latinos (31%), and insurance status for whites (40%). Experiences of discrimination in mental health/substance abuse visits were associated with less helpful treatment ratings for Latinos (AOR=0.09, P<0.05) and whites (AOR=0.25, P<0.01), and early treatment termination for blacks (AOR=13.38, P<0.05). Conclusions: Experiences of discrimination are associated with negative mental health/substance abuse treatment experiences and stopped treatment, and could be a factor in mental health outcomes.

Racial Differences in Veterans' Satisfaction With Addiction Treatment Services.

Objectives:Racial minorities experience lower rates of alcohol treatment completion than whites. Treatment satisfaction is an important factor in alcohol treatment retention, yet few studies have explored the satisfaction of racial minorities while in treatment. This study examined racial differences in addiction treatment satisfaction and explored factors that might mediate or moderate racial differences in satisfaction. Methods:We surveyed non-Hispanic black and non-Hispanic white veterans with an alcohol-related diagnosis about addiction treatment services at a large Veterans Affairs medical center. Treatment satisfaction was measured using the 8-item Client Satisfaction Questionnaire, dichotomized as low versus non–low satisfaction in analyses. The &khgr;2 and logistic regression methods were used to test for associations of race and sociodemographic characteristics with treatment satisfaction. Results:Among 271 black and 304 white veterans with an alcohol-related diagnosis, race was not statistically associated with treatment satisfaction in bivariate analyses (P > 0.05). However, we identified significant interactions of race with mental health diagnoses in predicting treatment satisfaction in multivariable analyses (adj odds ratio = 0.55; 95% confidence interval [CI] = 0.39–0.78). In post hoc comparisons among veterans with zero mental health diagnoses, black veterans had a greater probability of reporting low satisfaction than whites (marginal difference = 0.13; 95% CI = 0.04–0.22). In veterans with 4 or more diagnoses, whites had a greater probability than blacks of reporting low satisfaction (marginal difference = 0.28, 95% CI = 0.10–0.46). Regardless of race, past homelessness was associated with low satisfaction (adj odds ratio = 2.09; 95% CI = 1.19–3.67). Conclusions:Racial minorities, veterans with unstable housing, and white veterans with co-occurring mental health disorders may be at risk of experiencing low treatment satisfaction.

A national evaluation of homeless and nonhomeless veterans' experiences with primary care.

Persons who are homeless, particularly those with mental health and/or substance use disorders (MHSUDs), often do not access or receive continuous primary care services. In addition, negative experiences with primary care might contribute to homeless persons’ avoidance and early termination of MHSUD treatment. The patient-centered medical home (PCMH) model aims to address care fragmentation and improve patient experiences. How homeless persons with MHSUDs experience care within PCMHs is unknown. This study compared the primary care experiences of homeless and nonhomeless veterans with MHSUDs receiving care in the Veterans Health Administration’s medical home environment, called Patient Aligned Care Teams. The sample included VHA outpatients who responded to the national 2013 PCMH-Survey of Health Care Experiences of Patients (PCMH-SHEP) and had a past-year MSHUD diagnosis. Veterans with evidence of homelessness (henceforth “homeless”) were identified through VHA administrative records. PCMH-SHEP survey respondents included 67,666 veterans with MHSUDs (9.2% homeless). Compared with their nonhomeless counterparts, homeless veterans were younger, more likely to be non-Hispanic Black and nonmarried, had less education, and were more likely to live in urban areas. Homeless veterans had elevated rates of most MHSUDs assessed, indicating significant co-occurrence. After controlling for these differences, homeless veterans reported more negative and fewer positive experiences with communication; more negative provider ratings; and more negative experiences with comprehensiveness, care coordination, medication decision-making, and self-management support than nonhomeless veterans. Homeless persons with MHSUDs may need specific services that mitigate negative care experiences and encourage their continuation in longitudinal primary care services.

Chronicity and Mental Health Service Utilization for Anxiety, Mood, and Substance Use Disorders among Black Men in the United States; Ethnicity and Nativity Differences

This study investigated ethnic and nativity differences in the chronicity and treatment of psychiatric disorders of African American and Caribbean Black men in the U.S. Data were analyzed from the National Survey of American Life, a population-based study which included 1859 self-identified Black men (1222 African American, 176 Caribbean Black men born within the U.S., and 461 Caribbean Black men born outside the U.S.). Lifetime and twelve-month prevalence of DSM-IV mood, anxiety, and substance use disorders (including Bipolar I and Dysthmia), disorder chronicity, and rate of mental health services use among those meeting criteria for a lifetime psychiatric disorder were examined. Logistic regression models were employed to determine ethnic differences in chronicity, and treatment utilization for disorders. While rates of DSM-IV disorders were generally low in this community sample of Black men, their disorders were chronic and remained untreated. Caribbean Black men born in the U.S. had higher prevalence of Post-Traumatic Stress Disorder, Major Depressive Disorder, and Alcohol Abuse Disorder compared with African American men. Foreign born Caribbean Black men experienced greater chronicity in Social Phobia and Generalized Anxiety Disorder compared to other Black Men. Utilization of mental health service was low for all groups of Black Men, but lowest for the foreign born Caribbean Black men. Results underscore the large unmet needs of both African American and Caribbean Black men in the United States. Results also highlight the role of ethnicity and nativity in mental disorder chronicity and mental health service utilization patterns of Black men.

Racial and Ethnic Minority Concentration in Veterans Affairs Facilities and Delivery of Patient-Centered Primary Care

Despite patient-centered medical home implementation by the Veterans Health Administration (VHA), delivery of patient-centered care varies across VHA facilities. Facility characteristics underlying this variation are not fully understood. This study used administrative data from 908 VHA outpatient facilities to examine the association of racial and ethnic minority patient concentration and other facility characteristics with facility ratings of patient-centered care. The primary finding was that patient-centered ratings were lower for facilities with medium or high concentrations of Hispanic patients (medium: estimate [Est] = -0.40, standard error [SE] = 0.20, P = 0.046; high: Est = -0.99, SE = 0.23, P < 0.001). In addition, patient-centered ratings decreased as patient panel sizes increased, especially among facilities with higher concentrations of black patients. This study indicates that efforts to improve patient-centered care may be needed at VHA facilities that serve Hispanic and VHA facilities with large panel sizes of high concentrations of black patients.

Using structured and unstructured data to refine estimates of military sexual trauma status among Us Military Veterans

Sexual trauma survivors are reluctant to disclose such a history due to stigma. This is likely the case when estimating the prevalence of sexual trauma experienced in the military. The Veterans Health Administration has a program by which all former US military service members (Veterans) are screened for military sexual trauma (MST) using a questionnaire. Administrative data on MST screens and a change of status from an initial negative answer to positive and natural language processing (NLP) on electronic medical notes to extract concepts related to MST were used to refine initial estimates of MST among a random sample of 20,000 Veterans. The initial MST positive screen of 15.4% among women was revised upward to 21.8% using administrative data and further to 24.5% by adding NLP results. The overall estimate of MST status in women and men in this sample was revised from 8.1% to 13.1% using both data elements.

Characteristics of the Highest Users of Emergency Services in Veterans Affairs Hospitals: Homeless and Non-Homeless.

Efforts are underway to understand recent increases in emergency department (ED) use and to offer case management to those patients identified as high utilizers. Homeless Veterans are thought to use EDs for non-emergent conditions. This study identifies the highest users of ED services in the Department of Veterans Affairs and provides descriptive analyses of these Veterans, the diagnoses for which they were seen in the ED, and differences based on their homeless status. Homeless Veterans were more likely than non-homeless Veterans to have >10 visits in the 2014 calendar year (12% vs. <1%). Homeless versus non-homeless Veterans with >10 visits were more often male, 10 ED visits were often treated for chest and abdominal pain, and back problems, whereas homeless Veterans were frequently treated for mental health/substance use. Tailored case management approaches may be needed to better link homeless Veterans with high ED use to appropriate outpatient care.